Over the past 17 years of working in the MSP compliance industry, I have noticed that few things can cause as much confusion when it comes to Medicare eligibility for children/kids. This blog is intended to clear up some of the confusion surrounding Medicare benefits for children to assist with settlement planning.

Medicare defines children/kids as anyone who is under the age of 22 and unmarried. Once a child/kid qualifies for Medicare benefits, they can keep Medicare coverage until the age of 26, as long as they are unmarried and continue to meet the qualifications.

Medicare coverage for kids is available but only in limited circumstances. For a child to be eligible for Medicare benefits, the following criteria must be met:

1. The child must have End Stage Renal Disease (ESRD) and need regular dialysis treatments or have recently had a kidney transplant

2. The child must have a parent or legal guardian who has earned at least six Social Security (SS) work credits in the last 3 years or is currently receiving Social Security Retirement benefits

Medicare defines a parent or legal guardian as either biological, adoptive, or stepparent. If the child is in the care of stepparents, the stepparents need to have been the child’s stepparents for at least one year for the child to be eligible for Medicare benefits if the other criteria have been met.

If the criteria have been met, the child will continue to receive Medicare benefits until 12 months after the last dialysis treatment or 3 years after a kidney transplant. Medicare coverage can restart if additional treatment is needed for ESRD.

If a child is between the ages of 20 and 22 and meets a few additional requirements, they may be eligible for Medicare benefits. Those additional requirements are:

1. The individual has been receiving Social Security Disability Insurance (SSDI) for at least 24 months

2. The disability began before the age of 18

3. The disability prevents the individual from working and is expected to last longer than one year

It is uncommon for a child to be eligible for Medicare benefits, but it is possible. Suppose you are settling a case for a minor who currently has ESRD or is between the ages of 20 and 22 and has a qualifying disability that started prior to age 18. In that case, there is a possibility that they may currently be receiving Medicare benefits.

If you are settling a case for a child who currently receives Medicare benefits, it is important to properly address Medicare as part of the settlement. Considering Medicare’s interests in settlements is how an injured party does their part in complying with the Medicare Secondary Payer Statute (MSP). This includes addressing past medical/conditional payments (Medicare liens) as well as Future Medical/conditional payments because the MSP does not distinguish between pre and post-settlement conditional payments. Considering Medicare’s past and future interests will ensure that the burden for payment of future medical treatment isn’t being shifted to Medicare and that Medicare benefits for the individual will be protected.

If you have additional questions on how to address Medicare’s past or future interests in a case, please click here.